Andrew Crane · Prevention of Future Deaths report

On 18 November 2016 an investigation was commenced into the death of Andrew Crane, age 53. The investigation concluded at the end of the inquest on 25 April 2018. The conclusion of the inquest was that Mr Crane died of natural causes. The medical cause of death was 1a) Acute myocardial insufficiency 1b) Coronary artery atherosclerosis 2) Long term smoking habit.

Mr Crane suffered a cardiac arrest in his cell on 16 November 2016 and he died despite efforts at resuscitation. The following non-causative failures were recorded in the conclusion: Mr Crane had previously been noted to have high blood pressure and high blood sugar, but there was a failure by the prison healthcare system to follow up and monitor these results; there was a failure by the ambulance service to ensure that an ambulance was dispatched promptly.

Although both the prison and ambulance service have made amendments to their systems to address other matters of concern which arose during the inquest, the following matters remain:

(1) Mr Crane had complained of chest pain shortly before his cardiac arrest. The prison officer did not consider that he was unwell and so asked the healthcare nurse to attend. According to PSI 3/2013 and the prison’s emergency response policy, a complaint of chest pain should result in a Code Blue call. There was a lack of clarity amongst witnesses as to what, if any, discretion should be given in these circumstances to a prison officer who thinks that a complaint of chest pain does not require a Code Blue response.

(2) A Code Blue was called when Mr Crane collapsed, and at this stage an ambulance was called. After this call, it became clear that Mr Crane was not breathing and CPR was commenced, but this further information was not passed to the ambulance service. This information would have changed the priority of the ambulance response.